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Agent Account Request

Complete the fields below, then make a note of the username and password you choose. You'll need them to log in to your account once we activate it. Click any help symbol for help.

Your Privacy is Important. Priority Health has a strict Privacy Policy. We will not share your account information with others.

(required) Indicates required information

Agent Information
Agency/Agent Name help
as it appears on Remittance Advice
Broker Number help
Address Line 1 (Street Address) help
Address Line 2
Zip Code
Office Contact/Manager help

User Information
First Name
Last Name
Email Address help
Phone help
( ) - ext.
( ) -
Username help
(6-32 characters)
Password help
(8+ characters, at least 1 number, case-sensitive)
Password Confirmation help
Tools for Agents
Select all the tools that you would like associated with your account. Click any tool name to read a description.
Commissions - Payment Inquiry
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